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HomeMy WebLinkAboutTR-5922 �' .fir "`�.. �^ �•`:1�,-. IRP r� •� ��• `�.0 / .,..try- s -. Board Of Southold Town Trustees SOUTHOLD, NEW YORK 1..� DATE: May...... 004 26r....2 PERMIT NO. .. ................. ........ ANN CLEMENTS ISSUEDTO ............................................. ........................................ R Pursuant to the provisions of Chapter 615 of the Laws of " y the State of New York, 1893; and Chapter 404 of the Laws of the .. State of New York 1952; and the Southold Town Ordinance en- — --titTe�:,'REGgLATING A-ND-'HE-PL-4C--ING-OF—OBSTRUCTIONS-- _. IN AND ON TOWN WATERS AND PUBLIC LANDS and the I REMOVAL OF SAND, GRAVEL-OR OTHER MATERIALS FROM _ LANDS .UNDER TOWN'WATERS;'•.'. and in accordance with the May 26, Resolution of The Board adopted at a meeting held on .............................. 004 2 aid b . ............. and in consideration of the sum of ....250.00 p y , > Ann Clements . ...............: ....... Southold N. Y. and. subject to the of ................................. .............................................. Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: _ .�... 1 Wetland Permit to construct a 3H sq.ft. ground-level deck, r" with the condition there is 1/4" spacing between the deck ; boards and a porous surface underneath the deck. all in accordance with the detailed specifications as presented in 1� .the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- r by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board .as of this date. = ; 0 ,�o Trustees .._y .,y.�{,-ram• �s-�-. •,�+ v�.••g-- _v--^— -s�r-r.�Y. •+�'. s dk� •`... ..- / n�: - ram. �.,, t -h 1X 9� i TERMS and COMMONS Ann Clements The Permittee residing at 560 Ruch Lane, Southold N. Y., as part- of the consideration for the issuance of the Permit does understand and prescribe to the fol- lowiug: I. That the said Board of Trustees and the Town of.Southold am released -from any sad all damages, or daims for damages, of suits arising.directly or indirectly as a result of any oiler- --- does—performed—puraiant co this--permit, and he aid_i' itoee__ l,�t __or expense----- „ defend any and all.such suits-initiated by third Vattia, and the said Permittee assumes full liability — with respect thereto, to the complete'exclusion of the Board-of Trustees of the Town of Southold , 2. That this Permit is valid .for a period of . 24 tuts, which is 464sidered to be the estimated time'required to complete the work involved, bat'should dreumstantes warr=4 request. for an extension ,may be made to the Board at a later date. - 3. That this Permit should be retained indefinitely, of as long as the said Permittee wishes to maintain the structure or project involved, to provide evidence to anyone concerned that auth- orization was originally obtained. 4. That the work involved will be subject to the iaspect m and approval of the Board or its agents, and non-compliance with the provisions of the originating application, maybe cause for revocation of this Permit by resolution of the said Board. 5. That there will be no unreasonable interference with navigation as a result of the work herein authorized. 6. That there shall be no interference with the tight of :the public to pass and repass along the beach between high and low water marks. r: 7. That if future operations of the Town of Southold requite the.removal and/or alterations in the location of the work herein aat wbmd, or If, in the opinion of-tee.Board of Trustees, the. work.shall cause unreasonable obstruction to free navigation, the said Permittee will be requited, upon due notice, to remove or alter this work or project herein stated without expenses to the Town of Southold. B. That the said Board will be notified by the Permittee of the completion.of the work oath : orined. 9. That the 'Permittee will obtain all other permits and consents that may be required sup- plemental to this permit which way-be subject to revoke upon failure to obtain same. } Albert J.Krupski,President Town Hall James King,Vice-President O$VFFD(l�'C 53095 Route 25 P.O.Box 1179 Artie Foster �0 ��j J` 'f' Southold,New York 11971-0959 Ken Poliwoda o Peggy A.Dickerson ti Z Telephone(631) 765-1892 Qy Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD YOU ARE REQUIRED TO CONTACT THE OFFICE OF THE BOARD OF TRUSTEES 72 HOURS PRIOR TO COMMENCEMENT OF THE WORK, TO MAKE AN APPOINTMENT FOR A PRE-CONSTRUCTION INSPECTION. FAILURE TO DO SO SHALL BE CONSIDERED A VIOLATION AND POSSIBLE REVOCATION OF THE PERMIT. Mow INSPECTION SCHEDULE Pre-construction, hay bale line 1st day of construction % constructed ✓ Project complete, compliance inspection. _ � ,c Albert J. Krupski, President Oar QG Town Hall James King,Vice-President �� 'yam 53095 Route 25 Artie Foster ti P.O.Box 1179 Ken Poliwoda I Southold, New York 11971-0959 Peggy A. Dickerson '!'�Q aQ� Telephone(631) 765-1892 1 `�► Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 26, 2004 Ms. Ann Clements 345 West 13t' St., #3A New Yo.rk,.NY 1.0014-1255 RE: ANN D. CLEMENTS 560 RUCH LANE, SOUTHOLD SCTM#52-2-25 Dear Ms. Clements: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, May 26, 2004 regarding the above matter: WHEREAS, ANN CLEMENTS applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated April 15, 2004, and, WHEREAS, said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on May 26, 2004, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standards set forth in Chapter 97 of the Southold Town Code, 2 WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees approve the application of ANN D. CLEMENTS to construct a 300 sq.ft. ground-level deck, with the condition there is '/" spacing between the deck boards and a porous surface underneath the deck. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of$50.00 per inspection. (See attached schedule.) Fees: $50.00 Very truly-yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/Ims i :f A' / _. NoRTti l8 �� II N/F BARNES N 34°45'00" 18.5.26' N M / i r 1 8 9 2 _ ~MOH rFD. Z 4v,,/ ` /moo ����� /,0 I / tOA / LEANING WEST y NYT 0 CHIMNEY ON �IIE 14 I I I I // 6.0' - r.. ® 111 I I I I I U ONE-STORY \\ p `111 I L, I I I o RESIDENCE ® I IIII II I FIRST FLOOR EL 24.02 co I � �qq N I I I I I I I I I 8.5' T4.9� �lj v I I III I I I I I N N P FRAME GI Fz 2 N GARAGE Cp ('' I I I I I I I I I \ 18.5' S I 163.80', 7.6' I o N F McCABE CO MON FD. h c)/ z/s ralda GUARANTEES INDICATED H E ON SHALL RUNE��J� ONLY TO THE PERSON FO WHOM THE SURVEY IS PREPARED, AND ON HI BEHALF TO THE ELE TIONS S R TITLE COMPANY, GOVERNM TAL AGENCY, JJ IN 19 929 N LENDING INSTITUTION, IF LI TED HEREON, AND TO THE ASSIGNEES OF TH LENDING INSTITUTION. 9 GUARANTEES ARE NOT TR I TO ADDITIONAL INSTITU77ONS DENT OWNERS. , �004 'UNAUTHORIZED ALTERATION OR ADDITION TO THIS APR SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCA77ON LAW. ` COPIES OF THIS SURVEY MAP NOT BEARING S0Uth0Id T THE LAND SURVEYORS EMBOSSED SEAL SHALL Board of Trusstete es �J NOT BE CONSIDERED TO BE A VALID TRUE COPY. SURVEYED: 17 AUGUST 2000 SURVEY OF TM# 1000-052-02-025 DESCRIBED PROPERTY SCALE 1"= 30' SITUATE AREA = 17,905.533 S.F. ARSHAMOMOQUE (SOUTHOLD) O.411R1 ACRES TOWN OF SOUTHOLD SUFFOLK COUNTY, N.Y. SURVEYED BY STAEY SURVEYED FOR: ANN DOBSON CLEMENTS P.O. B0 J. ISAKSEN, JR. P.O. OX 294 NEW SUFFOLK. N.Y. 11956 631—734-5835 GUARANTEED TO: ANN DOBSON CLEMENTS r---= -- --- FIDELITY NATIONAL TITLE INS. CO. 'LICEN LAND S' V YOR NYS L'c. No. 492 OOR928 1. 10 SEP 03 ADD ELEVATIONS & CONTOURS. �► Albert J.Krupski,President S�FFO( ��� C� Town Hall James King,Vice-President Gy� 53095 Route 25 Artie Foster o - P.O.Box 1179 Ken Poliwoda ccx Southold,New York 11971-0959 � T Peggy A.Dickerson y ��� Telephone(631) 765-1892 Fax(631)765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD TO: t r\n C' 0 lyto(1tn J Please be advised that your application dated has been reviewed by this Board at the regular meeting of I (n Iby and the following action was taken: �)Application Approved (see below) Application Denied (see below) Application Tabled (see below) If your application is approved as noted above, a permit fee is now due. Make check or money order payable to the Southold Town Trustees. The fee is computed below according to the schedule of rates as set forth in the instruction sheet. The following fee must be paid within 90 days or re-application fees will be necessary. COMPUTATION OF PERMIT FEES: TOTAL FEES DUE: $ 5D iC SIGNED: PRESIDENT, BOARD OF TRUSTEES o��S�FfO`�c�o Town Hall Telephone co 2 53095 Route 25 (631)765-1892 P.O.Box 1179 Southold,New York 11971-0959 CONSERVATION ADVISORY COUNCIL TOWN OF SOUTHOLD At the meeting of the Southold Town Conservation Advisory Council held Tuesday, May 11, 2004, the following recommendation was made: Moved by William Cook, seconded by Don Wilder, it was RESOLVED to recommend to the Southold Town Board of Trustees APPROVAL of the Wetland Permit application of ANN D. CLEMENTS to construct a 300 sq.ft. ground-level deck. Located: 560 Ruch Lane, Southold. SCTM#52-2-25 Vote of Council: Ayes: All Motion Carried 1 New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40 -SUNY, Stony Brook, New York 11790-2356 Phone: (631)444-0365 • FAX: (631)444-0360 - Website: www.dec.state.ny.us Erin M.Crotty Commissioner Letter of Non-Jurisdiction -Tidal Wetlands Act January 30, 2004 Ann D. Clements 345 W 13th St New York NY 10014 Dear Ms. Clements: Re: Clements Property, 560 Ruch Lane, Southold SCTM: 1000-052-02-25 DEC No. 1-4738-03207/00001 Based on the information you have submitted, the New York State Department of Environmental Conservation has determined that the property landward of the 10 feet elevation contour, as shown on the survey prepared by Stanley J. Isaksen, Jr., dated August 17, 2000, is beyond the jurisdiction of Article 25 (Tidal Wetlands). Therefore;`in.accordance with the current Tidal Wetlands Land Use Regulations (6 NYCRR Part 661'),Ino permit is required under the Tidal Wetlands Act. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary, as indicated above, without a permit. It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within tidal wetlands jurisdiction which may result from your project. Such precautions may include maintaining an adequate work area between the tidal wetland jurisdictional boundary and your project (i.e., a 15 to 20 feet wide construction area) or erecting a temporary fence, barrier, or hay bale berm. Please be further advised that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies. Very truly yours, George-W Harhmartfi Deputy'Permif Administrator7' cc: Marine Habitat Protection DEPARTMENT OF THE ARMY NEW YORK DISTRICT,CORPS OF ENGINEERS JACOB K.JAVITS FEDERAL BUILDING NEW YORK,N.Y.10278-0090 REPLY TO JA N ATTENTION OF: ���""""'888 Eastern Permits Section SUBJECT: Joint Application with New York State Department of Environmental Conservation Ann Dobson Clements 345 West 13th St #3A. ,New York,NY 10014 Dear Ms. Clements: We have recently received a copy of the Joint Application for Permit you filed with the New York State Department of Environmental Conservation(NYSDEC). Please be advised we have reviewed the Joint Application, and based solely upon the information provided,it appears that a Department of the Army is not required for your proposal. The Department of the Army regulates construction activities in navigable waterways and discharges of dredged or fill material into water of the United States, including inland and coastal wetlands. If your proposal would involve such work, and has not been portrayed as such in your Joint Application, you should contact this office immediately so that a project-specific determination can be made as to whether a Department of the Army permit will be required. Any inquires should be directed to the Regulator-of-the-Day at 212-264-6731. Sincerely, Mark Steven Roth Acting Chief,Eastern Permits Section DEC Application No. 1-4738-03297/00001 - a h g vuo ,i' Q� 1 ^• tQ,E� �M � t 1 FM Pdl;F P6 d O Ol.l O M1 � � Y o 0 O IL1uG �s s z s d �4 '�'�' iy1G .L0EPi5011 . ST • I LS.t<I / / I \./ POPRmqu,,..m '�.. ✓., a c9uG vseim �\ TOFN a SOURgID p��J/ � !•e� 59.Eo J I / o '\ t(D J eL3 (� PECWC l4ro TRUST 'O\ �O\ 0 S m1 yJ , FOP PIRGL m O. \ fni P.RLEEL Ml O'G �fG SEE 6[L NO. FOR P.PML tQ \ OSF-OE-OER 056-01-0iLt SEE SEL 10. • d -- 096-01-006 mt..— L� SFF EEL N0.O56 1.-_ \ L..P+.. 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IntSer�ctVt�craoft �841C Y1+Srsr� V n .d. ._ i 8•v14 f �3 � , � r � LEE M EH S May 15, 2004 Dear Lauren, Please find enclosed the notarized affidavit of posting pertaining to my Trustee permit application for a deck. This is scheduled for review on May 26 but I will be out of town attending my daughter' wedding and will not be able to attend. If necessary, please make the Board aware of this. Thanks for all your help. Best regards, pECE Ann Clements MAY 18 2004 Southold Town Board of Trustees 345 W. 13th Street, Suite 3A, New York, New York 10014-1207 VOX 212.807.0999 FAX 212.807.0998 CELL 917.806.5434 email: anndclements@aol.com I Albert J:Krupski,President �� C'� Town Hall James King,Vice-President 53095 Route 25 Artie Foster : P.O.Box 1179 ti 2 Southold,New York 11971-0959 Ken Poliwoda io Peggy A.Dickerson .fi ,� Telephone(631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only _Coastal Erosion Permit Application eland Permit Application / 1'ajor Minor _Waiver/Amendment/Cl—ges oolteceived Application: iReceived Fee:$dt _eEompleted Application D Ea E _Incomplete '' _SEQRA Classification: Type I Type II Unlisted Coordination:(date seVtiv APR 15 2004 _ _CAC Referral Sent: P "Y ,mate of Inspection: _Receipt of CAC Report: Southold Town _Lead Agency Determination: Board of Trustees _Technical Review: ,oPublic Hearing Held: Resolution: 1 Name of Applicant ` y\ Address 3 ' .u3`C� - ZS Phone Number:( Suffolk County Tax Map Number: 1000 - 5� ON, Property Location: Stt C'7RoC� k�h'C.. �S �\� Gam- Cdo AI _ (pro ide LILCO Pole#, dis ce to cross streets, an location) AGENT: (If applicable) Address: Phone: ` r Board of Trustees Application GENERAL DATA Land Area(m square feet). .3 4 ar, k. (n'�ve- Area Zoning: ��SI�ClQk•C (C.u� Previous use of property: lesl-dLa ( � Intended use of property: (6-L'J-�[' Prior permits/approvals for site improvements: Agency Date �•� .e- COL lk ; IrJOA . `to be- PAICCJ2— U No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspend d by a governmental agency? No Yes If yes, provide explanation: Project Description(use attachments if necessary): V-OX• 3CO s lC Ck e r, &zu- Board of Trustees Application WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: 5 oki ti� (� �t°cy_ 01, Area of wetlands on lot: �• square feet Percent coverage of lot: 0/0 Closest distance between nearest existing structure and upland edge of wetlands: 70 feet Closest distance between nearest proposed structure and upland edge of wetlands: 8 feet Does the project involve excavation or filling? XNo Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate):11 Board of Trustees Application COASTAL EROSION APPLICATION DATA Purposes of proposed activity: C l (— Are wetlands present within 100 feet of the proposed activity? No�_Yes Does the project involve excavation or filling? No Yes If Yes, how much material will be excavated? (cubic yards) How much material will be filled? (cubic yards) Manner in which material will be removed or deposited: Describe the nature and extent of the environmental impacts reasonably anticipated resulting from implementation of the project as proposed. (Use attachments if necessary) rou ka l e a a to �jcls-hvoC � `-' existvvcl do W(k Ow.S to be- Cf Uqx \ ���� doors 617.20 SEQR PROJECT, ID NUMBER APPENDIX C STATE ENVIRONMENTAL QUALITY REVIEW SHORT ENVIRONMENTAL ASSESSMENT FORM for UNLISTED ACTIONS Only PART 1 -PROJECT INFORMATION (To be completed by Applicant or Project Sponsor) 1.APPLICANT/SPONSOR 2.PROJECT NAME C cLt�.tul s OU In e 3.PROJECT LOCATION: Municipality ag Joci, Lkt &XUd County C 4.PRECISE LOCATION: Street Addess and Road Intersections, Prominent landm etc -or provide map S-60 S �.�olat.� I k)oV lAam—`k&LCLo� IN }}(M,,,;1e AIM-• U � 5.IS PROPOSED ACTION: ❑ New ❑Expansion 9Modification/alteration y-, 6.DESCRIBE PROJECT BRIEFLY: l ��` ^ CZ t� O IM1/\,p✓� \`^-a�-� a 7.AMOUNT OF LAND AFFECTED: Initially acres Ultimately acres 8.WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER RESTRICTIONS? FYes ❑ No If no,describe briefly: FFR AT IS PRESENT LAND USE IN VICINITY OF PROJECT? (Choose as many as apply.) esidential ❑Industrial ❑Commercial ❑Agriculture ❑Park/Forest/Open Space ❑Other (describe) 10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGGEJWY (Federal, State or Local) I V IYes ❑No If yes, list agency name and permit / approval: � S'ul�h.ol�lo����ild���,. �•e � � • L ,e. Srt'c.�',e. JU 11.DOES ANY ASPECT OF THE ACTION HAVE CURR TLY VALID PERMIT OR APPROVAL? MYes El No If yes, list agency name and permit / approval: � 12. AS A RE T OF PROPOSED A ION WIL EXISTING PERMIT/ APPROVAL REQUIRE MODIFICATION? ❑Yes M No I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Applicant / Sponsor Na Date: aLSignature If the action is a Costal Area, and you are a state agency, complete the Coastal Assessment Form before proceeding with this assessment PART II - IMPACT ASSESSMENT(To be completed by Lead Agency) A. DOES ACTION CEED ANY TYPE I THRESHOLD IN 6 NYCRR,PART 617.4? If yes,coordinate the review process and use the FULL EAF. Yes ACTION B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR,PART 617.6? If No,a negative declaration mgbif superseded by another involved agency. Yes Lvj No C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING:(Answers may be handwritten,if legible) C1. Existing air quality,surface or groundwater quality or quantity,noise levels,existing traffic pattern,solid waste production or disposal, potential for erosion,drainage or flooding problems? Explain briefly: �O _ .. C2. Aesthetic,agricultural,archaeological,historic,or other natural or cultural resources;or community or neighborhood character?Explain briefly: C3. VegetalItioni or fauna,fish,shellfish or wildlife species,significant habitats,or threatened or endangered species?Explain briefly: 1� C) C4. A community's existing plans or goals as officially adopted,or a change in use or intensity of use of land or other natural resources?Explain briefly: ho C5. Growth,subsequent development,or related activities likely to be induced by the proposed action?Explain briefly: l C6. Long term,short term,cumulative,or other effects not identified in C1-05? Explain briefly: C7. Other impacts(including changes in use of either quanti or type of energy? Explain briefly: h -- D. WILL THE PROJECT HAVE AN IMPACT ON THE ENVIRONMENTAL CHARACTERISTICS THAT CAUSED THE ESTABLISHMENT OF A CRITICAL ENVIRONMENT AREA CEA)? If xes,ex lain briefl _ Yes o E. IS THERE,OR IS HERE LIKELY TO BE,CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS? If es ex lain: Yes 9No PART III-DETERMINATION OF SIGNIFICANCE(To be completed by Agency) INSTRUCTIONS: For each adverse effect identified above,determine whether it is substantial,large,important or otherwise significant. Each effect should be assessed in connection with its(a)setting(i.e.urban or rural);(b)probability of occurring;(c)duration;(d)irreversibility;(e) geographic scope;and (f)magnitude. If necessary,add attachments or reference supporting materials. Ensure that explanations contain sufficient detail to show that all relevant adverse impacts have been identified and adequately addressed. If question d of part ii was checked yes,the determination of significance must evaluate the potential impact of the proposed action on the environmental characteristics of the CEA. Check this box if you have identified one or more potentially large or significant adverse impacts which MAY occur.Then proceed directly to the FULL EAF and/or prepare a positive declaration. Check this box if you have determined,based on the information and analysis above and any supporting documentation,that the proposed actin WILL NOT result in any significant adverse environmental impacts AND provide, on attachments as necessary, the reasons supporting thi determination. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer(If different from responsible officer) SVFF�(� Town Hall Albert J.Krupski,President 0�,� CQG James King,Vice-President �`Z` �f.� 53095 Route 25 P.O.Box 1179 Artie Foster `y = Southold, New York 11971-0959 Ken Poliwoda v. Peggy A.Dickerson O,f•� O�� Telephone(631) 765-1892 Ql �a Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD BOARD OF TRUSTEES: TOWN OF SOUTHOLD --------------------------------------------------------------- In the Matter of the Application of --0 -------------------------- COUNTY OF SUFFOLK) STATE OF NEW YORK) AFFIDAVIT OF POSTING I, residing at 3 being duly sworn, depose and say: That on the /3day of k,t , 200 4I personally posted the property known as by placing the Board of Trustees official poster where it carf easily be seen, and that I have checked to be sure the poster has remained in place for eight days prior to the date of the public hearing. Date of hearing noted thereon to be held oZ AGN br1 Or cm�pt W Dated: (signature) Sworn to before me thi day of 200 otary Public NISE E.WALLEN ary Public,State of New Yodt No. 24-452761 8 Qualified in Kings County Commission Expires April 30.200i PROOF OF MAILING OF NOTICE ATTACH CERTIFIED MAIL RECEIPTS i rR o, ut (Domestic maii r .•. Name: J ! Er r/1 a >- S yG °� Postage $ 0.17 :U'rlITI+Ii: ic�4��ti p Certified Fee 70 p Postmark —i v 1 y � 'j,�j - (Endorsement Requlred) 1, G �� Here � � p Restricted Delivery Fee \ yerk.: ;GTV7F (Endorsement Required) 99 / ru 2 ru Total Postage&Fees $ 4.41) 04i t i Im 0 Sent To 'R o.PO sox Noo.. � cil[�vv C�nea!�, w r, :rr or f t `�' 44� STATE OF NEW YORK COUNTY OF SUFFOLK , residing at ,being duly sworn, deposes and says that on the day of �tees­Xpplication, , 200� , deponent mailed a true copy of the Notice set forth in the Board of r directed to each of the above named persons at the addresses set opposite there respective names; that the addresses set opposite the names of said persons are the address of said persons as shown on the current assessment roll of the Town of Southold; that said Notices were mailed at the United States Post Office at_���1,v-(k�� . UI� ,that said Notices were mailed to each of said persons by (certified) (registered)mail. Sworn to a re me s Day of 520 Notary Publ' DENISE E.WALLEN Notary Public,State of New York No. 24-4527618 Qualified in Kings County Commission Expires April 30,20Qi PROOF UN'1V1AtM G OF NOTICE ATTACH CERTIMP MAIL RECEIPTS Postal Service,. r` 0 potnestic Mail Only; Nan e: Addi cr 1,UV �' �is �...`u��t � r � � Q F -- mil. - ! Postage $ t�. } ' p certfned Fee SIT o K l 1=1 R t Required, t Fee �'� ,� P He e h (Endorsement Restricted Delivery Fee �{ I N (Endorsement Required) - Rl Total Postage S Fees $ 4.42 0'/^ ( z o m QSent To �i}y V - ----- ---(----------------- ------------- -------- �` 3`rlBef,Apt N.; - or PO t3oz No. �0 `11 =— JlrGs.l -- --------------- - -------------- c�ry were,zrP+a T G� ��? v(�� /YSM PS Form 3aoo,June 2002 See Reverse'for Instruction's" STj TE OF NEW YORK CO TNTY"OF SUFFOLK C C 1n- z) � ,residing at being duly sworn, deposes and says that on the day of J Z0� , deponent mailed a true copy of the Notice set Drih.in the Board o Trustees Application, directed to each of the above named per ins at the addresses set opposite there respective names;that the addresses set opr )site the names of said persons are the address of said persons as shown on the current ass, ssment roll of the nTown of Southold; that said Notices were mailed at the United States Post Off ce at �� � ti-X1U�. k k{ that said Notices were mailed to each of said persons by (ce, :ified) (registered)mail. 1 J f Sw ern to re que this IDa of i otary Pub -c DENISE E. 1 _N Notary Public, State of w York No. 24-452761 a Qualified in Kings County Commission Expires April 30, 2006 Board of Trustees Application County of Suffolk State of New York ZA BEING DULY SWORN DEPOSES AND AFFIRMS THAT FIVSHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS APPLICATION. �J Signature SWORN TO BEFORE ME THIS DAY OF 20 4ota Public GISLAINE AUGUSTIN Notary Public, State of New York No. 01AU6105405 Qualified in Queens County Commission Expires February 9, 20-Q� APPLICANT/AGENT/REPRESENTATIVE TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics prohibits conflicts of interest on the part of town officers and em to ees.The owse of this form is to provide information which can alert the town of possible conflicts of interest and allow it to take whatever action is necessary to avoid same. ,o►^" YOUR NAME: (Last name,first name,ipiddle mite ,unless you are applying in the name of someone else or other entity,such as a company.If so,indicate the.other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) Tax grievance Building _ Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest.`Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than`5%of the shares. YES NO v If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicantlagent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the . applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of 200_ Signature Print Name ltnvL iJ G 6meA43 Form TS I